Date_______________________________________________________
SS#_______________________________________________________
Patient Name________________________________________________
Last Name
__________________________________________________________
First Name Middle Initial
Address____________________________________________________
City_______________________________________________________
State__________________________ Zip Code____________________
E-mail_____________________________________________________
Sex M F Age________________
Birth date___________________________________________________
Married Widowed Single Minor Separated Divorced Partnered for _____years Occupation__________________________________________________
Patient Employer/School_______________________________________
Employer/School Address______________________________________
Spouse’s Name______________________________________________
Birth date___________________________________________________
Spouses’s Employer__________________________________________
Whom may we thank for referring you?___________________________
Do you have Insurance? ___Yes ___No
If Yes, Who: ________________________________________________
W ELCOME
PATIENT INFORMATION
Reason for Visit______________________________________________________
___________________________________________________________________
When did symptoms occur?____________________________________________
___________________________________________________________________
Is this condition getting progressively worse? ______Yes ______No Have you had this problem before? ______Yes _____No
If Yes, when?_________________________________________________________
___________________________________________________________________
Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain):
_____1_____2_____3_____4_____5_____6____7____8____9____10
Sleep Habits:
Difficulty Falling Asleep ___Yes ___No Difficulty Staying Asleep ____Yes ____No
Urine:
How Often: _______Frequent ________Scanty
Color: _______Clear ______Yellow ______Dark Yellow
Bowel Movements:
How Often:
Constipation _____Yes _____No Diarrhea _____Yes _____No Odor _____Yes _____No Loose _____Yes _____No Color ______Black _______Brown _______Mucous
Flatulence _____Yes _____No Chills/Fever _____Yes _____No Perspiration _____Yes _____No ______Spontaneous
Diet Cravings: _____Sweet ______Salt ______Spicy ______Sour _____Pepper
Menses: (Women Only)
Clotting ____Yes ____No Pain ____Yes ____No Length ________Abnormal _________Normal
Duration ________Abnormal _________Normal Color ________Abnormal _________Normal Quality ________Abnormal _________Normal
Flow ________Scanty _________Heavy _____Normal Onset/Age _________
Birth Controls _______Yes _____No Age _______
Hormone Replacement Therapy: _______Yes _____No
If yes, When________________________________________________________
Discharge ________Yes ______No
What treatment have you already received for your condition?
__________Medications ____________Surgery _____________Physical Therapy ______________Chiropractic Services _________None _______________Other
Name and address of other doctor(s) who have treated you for your condition:
__________________________________________________________________
Date of your last Physical Exam_________________________________________
Date of your last X-Ray:________________________________________________
PATIENT CONDITION
Home Phone (___)______________________________________
Cell Phone (___)_______________________________________
Best time to reach you __________________________________
IN CASE OF EMERGENCY, CONTACT:
Name________________________________________________
Relationship__________________________________________
Home Phone (___)_____________________________________
Work Phone (___)_____________________________________
PHONE NUMBERS
NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME 03903
Place a mark on “Yes” or “No” to indicate if you have had any of the following:
Exercise: ___________None __________Moderate ___________Daily __________Heavy Work Activity: ___________Sitting __________Standing ___________Light Labor __________Heavy Labor
Habits: ______Smoking ________Alcohol ________Coffee/Caffeine Drinks _____________________High Stress Level _____Packs/Day ________Drinks/Week ________Cups/Day _____________________Reason Are you Pregnant? ______Yes ____No If Yes, Due Date____________
Injuries/Surgeries you have had: Such as:
____________________________________________Falls ___________________________________________________Head Injuries _____________________________Broken Bones ______________________Dislocations ___________________________Other
Medications: Allergies: Vitamins/Herbs/Minerals:
_______________________________________ __________________________________ ___________________________________
________________________________________ __________________________________ ___________________________________
________________________________________ __________________________________ ___________________________________
FOR DOCTOR USE ONLY: DO NOT WRITE BELOW
Spirit:______________________________________________ Complexion: ________Pale ________Yellow ________Red ________Blue ________Green Odor: ______Sweet _______Scorched ______Rotten ______Putrid Voice: ______Fast ______Slow ______SingSong ______Hollow _____Deep Angry: ____Yes ____ Meek: ____Yes ____No Fast: ____Yes ____No Body Color: _______White ______Yellow ____Other Tongue: _______Red _______Pale _______Purple _______Spots _______White ______Yellow _______Dry Yellow _______Scalloped ________Toothmarked Size & Shape: _______Large _______Swollen _____Stiff ______Flaccid _____Long _____Short _____Cracked _____Quivering ______Deviated _____Toothmarked Pulse: ______Rapid _____Slow _____Full ____Empty ____Wiry ____Slippery ____Big ___Minute ___Superficial ___Deep ___Frail ______Tight _____Long ____Short ____Knotted ____Soggy ____Intermittent ____Hidden ____Hollow ____Leather ______Hurried ____Flooding ____Confined ____Scattered
Other Information:_________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PATIENT INFORMATION
AIDS/HIV ___Yes ___No Diabetes ___Yes ___No Migraine Headaches ___Yes ___No Rheumatic Fever ___Yes ___No
Alcoholism ___Yes ___No Emphysema ___Yes ___No Miscarriage ___Yes ___No Scarlet Fever ___Yes ___No
Allergy Shots ___Yes ___No Epilepsy ___Yes ___No Mononucleosis ___Yes ___No Stroke ___Yes ___No
Anemia ___Yes ___No Fractures ___Yes ___No Multiple Sclerosis ___Yes ___No Suicide Attempt ___Yes ___No
Anorexia ___Yes ___No Glaucoma ___Yes ___No Mumps ___Yes ___No Thyroid Problems ___Yes ___No
Appendicitis ___Yes ___No Goiter ___Yes ___No Osteoporosis ___Yes ___No Tonsillitis ___Yes ___No
Asthma ___Yes ___No Gonorrhea ___Yes ___No Pacemaker ___Yes ___No Tuberculosis ___Yes ___No
Bleeding Disorders ___Yes ___No Gout ___Yes ___No Parkinson’s Disease ___Yes ___No Tumors, Growths ___Yes ___No Breast Lump ___Yes ___No Heart Disease ___Yes ___No Pinched Nerve ___Yes ___No Typhoid Fever ___Yes ___No
Bronchitis ___Yes ___No Hepatitis ___Yes ___No Pneumonia ___Yes ___No Ulcers ___Yes ___No
Bulimia ___Yes ___No Hernia ___Yes ___No Polio ___Yes ___No Vaginal Infection ___Yes ___No
Cancer ___Yes ___No Herniated Disk ___Yes ___No Prostate Problem ___Yes ___No Venereal Disease ___Yes ___No
Cataracts ___Yes ___No Herpes ___Yes ___No Prosthesis ___Yes ___No Whooping Cough ___Yes ___No
Chemical Dependency ___Yes ___No High Cholesterol ___Yes ___No Psychiatric Care ___Yes ___No Other _________________
Chicken Pox ___Yes ___No Kidney Disease ___Yes ___No Rheumatoid Arthritis ___Yes ___No
Liver Disease ___Yes ___No Measles ___Yes ___No
NATURAL CARE WELLNESS CENTER
DR. SCOTT AND DR. JODY FERREIRA
6 SEELEY LANE (RT. 236)
ELIOT, ME 03903
INDIVIDUAL PATIENTS’ AUTHORIZATION
This authorization is to confirm or deny the use or disclosure of protected health information.
Patient’s Name: __________________________________________Date: ________
Please initial on all that apply. If you do not agree with any statements, please mark an X on the blank to confirm that you have read and understood the statement.
___ I authorize the release of my medical records to my family practitioner or other physician. List Names _____________________________________________________
___ I authorize the release of my medical records to my health insurance company for payment of services rendered.
___ I authorize the release of my medical records to any third party payer including insurance, workman compensation, attorney, auto insurance, etc.
___ I authorize NATURAL CARE WELLNESS CENTER to send information to my house concerning birthdays or newsletters, etc.
___ I authorize NATURAL CARE WELLNESS CENTER to leave any message on my home or work answering machine such as appointment time.
NATURAL CARE WELLNESS CENTER
DR. SCOTT AND DR. JODY FERREIRA
6 SEELEY LANE (RT. 236)
ELIOT, ME 03903
AUTHORIZATION, ASSIGNMENT AND CONSET TO TREAT
Our office policy requires payment in full for all services rendered a the time of visit, unless other arrangements have been made with the business manager. If the account is not paid within 90 days of the date of service, and no financial arrangement has been made, you will be responsible for any expenses incurred in collecting your account.
________, I hereby authorize NATURAL CARE WELLNESS CENTER to bill the insurance company for services rendered on my behalf. The bulling of such services are a privilege and not a guarantee of coverage. I further authorize the physician and/or supplier to release any information required to process insurance claims.
________, I authorize the direct payment to you any sum I now or hereafter owe, by my attorney out of the proceeds of any settlement of my case, and/or by any insurance company obligated to make payment to me or you based in whole or part upon the charges made for the services.
________, I understand that whatever amounts you do not collect from the insurance company and/or attorney, whether it be all or part of what is due, I personally owe and agree to pay you.
I hereby authorize the doctor’s of NATURAL CARE WELLNESS CENTER and whomever they designate as their assistant or authorized representative to administer chiropractic care, acupuncture or colon hydrotherapy as they deem necessary. We invite you to discuss openly treatment, services, and charges rendered at this office, so that there is mutual agreement and clarity.
I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes in my medical status.
Signature: ______________________________________ Date: _________
Signature of Guardian if Patient is under 18 years of age:
_______________________________________________Date: _________
